Provider Demographics
NPI:1558343442
Name:PERELLIS, DAVID H (DMD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:H
Last Name:PERELLIS
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:9451 WESTPORT ROAD
Mailing Address - Street 2:SUITE 109
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40241
Mailing Address - Country:US
Mailing Address - Phone:502-412-5900
Mailing Address - Fax:502-412-3005
Practice Address - Street 1:9451 WESTPORT ROAD
Practice Address - Street 2:SUITE109
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40241
Practice Address - Country:US
Practice Address - Phone:502-412-5900
Practice Address - Fax:502-412-3005
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-16
Last Update Date:2015-04-16
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
KY61801223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY60061801Medicaid